Methods for creating tissue effect utilizing electromagnetic energy and a reverse thermal gradient

ABSTRACT

A method of creating a tissue effect at a tissue site delivers electromagnetic energy through a skin surface from an electromagnetic energy delivery device coupled to an electromagnetic energy source. At least one of the electromagnetic energy delivery device or electromagnetic energy source includes a memory. A reverse thermal gradient is created through the skin surface to sufficiently heat an underlying tissue site to provide that a temperature of the skin surface is lower than a temperature of the underlying tissue. Information is stored from the memory to facilitate operation of at least one of the electromagnetic energy delivery device or the electromagnetic energy source. Electromagnetic energy is applied through the skin surface to the underlying tissue. A tissue effect is created on at least a portion of the tissue site.

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application is a continuation-in-part of U.S. Ser. No. ______, filed Mar. 25, 2003 and identified as attorney reference number 39238-0011, which is a continuation-in-part of U.S. Ser. No. 10/072,475 filed Feb. 6, 2002 and a continuation-in-part of U.S. Ser. No. 10/072,610 filed Feb. 6, 2002 both of which are continuations-in-part of U.S. Ser. No. 09/522,275, filed Mar. 9, 2000, which claims the benefit of U.S. Ser. No. 60/123,440, filed Mar. 9, 1999. This application is also a continuation-in-part of U.S. Ser. No. 10/026,870, filed Dec. 20, 2001 which is a continuation of U.S. Ser. No. 09/337,015 filed Jun. 30, 1999 which is a continuation-in-part of U.S. Ser. No. 08/583,815, filed Jan. 5, 1996, U.S. Ser. No. 08/827,237, filed Mar. 28, 1997, U.S. Ser. No. 08/914,681, filed Aug. 19, 1997 and U.S. Ser. No. 08/942,274, filed Sep. 30, 1997, which are all fully incorporated herein by reference.

BACKGROUND OF THE INVENTION

[0002] 1. Field of the Invention

[0003] This invention relates generally to methods for creating a tissue effect, and more particularly to methods for creating a tissue effect using an electromagnetic energy delivery device and a reverse thermal gradient.

[0004] 2. Description of Related Art

[0005] The human skin is composed of two elements: the epidermis and the underlying dermis. The epidermis with the stratum corneum serves as a biological barrier to the environment. In the basilar layer of the epidermis, pigment-forming cells called melanocytes are present. They are the main determinants of skin color.

[0006] The underlying dermis provides the main structural support of the skin. It is composed mainly of an extra-cellular protein called collagen. Collagen is produced by fibroblasts and synthesized as a triple helix with three polypeptide chains that are connected with heat labile and heat stable chemical bonds. When collagen-containing tissue is heated, alterations in the physical properties of this protein matrix occur at a characteristic temperature. The structural transition of collagen contraction occurs at a specific “shrinkage” temperature. The shrinkage and remodeling of the collagen matrix with heat is the basis for the technology. Although the technology can be deployed to effect other changes to the skin, skin appendages (sweat glands, sebaceous glands, hair follicles, etc.), or subcutaneous tissue structures.

[0007] Collagen crosslinks are either intramolecular (covalent or hydrogen bond) or intermolecular (covalent or ionic bonds). The thermal cleavage of intramolecular hydrogen crosslinks is a scalar process that is created by the balance between cleavage events and relaxation events (reforming of hydrogen bonds). No external force is required for this process to occur. As a result, intermolecular stress is created by the thermal cleavage of intramolecular hydrogen bonds. Essentially, the contraction of the tertiary structure of the molecule creates the initial intermolecular vector of contraction.

[0008] Collagen fibrils in a matrix exhibit a variety of spatial orientations. The matrix is lengthened if the sum of all vectors acts to lengthen the fibril. Contraction of the matrix is facilitated if the sum of all extrinsic vectors acts to shorten the fibril. Thermal disruption of intramolecular hydrogen bonds and mechanical cleavage of intermolecular crosslinks is also affected by relaxation events that restore preexisting configurations. However, a permanent change of molecular length will occur if crosslinks are reformed after lengthening or contraction of the collagen fibril. The continuous application of an external mechanical force will increase the probability of crosslinks forming after lengthening or contraction of the fibril.

[0009] Hydrogen bond cleavage is a quantum mechanical event that requires a threshold of energy. The amount of (intramolecular) hydrogen bond cleavage required corresponds to the combined ionic and covalent intermolecular bond strengths within the collagen fibril. Until this threshold is reached, little or no change in the quaternary structure of the collagen fibril will occur. When the intermolecular stress is adequate, cleavage of the ionic and covalent bonds will occur. Typically, the intermolecular cleavage of ionic and covalent bonds will occur with a ratcheting effect from the realignment of polar and nonpolar regions in the lengthened or contracted fibril.

[0010] Cleavage of collagen bonds also occurs at lower temperatures but at a lower rate. Low-level thermal cleavage is frequently associated with relaxation phenomena in which bonds are reformed without a net change in molecular length. An external force that mechanically cleaves the fibril will reduce the probability of relaxation phenomena and provides a means to lengthen or contract the collagen matrix at lower temperatures while reducing the potential of surface ablation.

[0011] Soft tissue remodeling is a biophysical phenomenon that occurs at cellular and molecular levels. Molecular contraction or partial denaturization of collagen involves the application of an energy source, which destabilizes the longitudinal axis of the molecule by cleaving the heat labile bonds of the triple helix. As a result, stress is created to break the intermolecular bonds of the matrix. This is essentially an immediate extra-cellular process, whereas cellular contraction requires a lag period for the migration and multiplication of fibroblasts into the wound as provided by the wound healing sequence. In higher developed animal species, the wound healing response to injury involves an initial inflammatory process that subsequently leads to the deposition of scar tissue.

[0012] The initial inflammatory response consists of the infiltration by white blood cells or leukocytes that dispose of cellular debris. Seventy-two hours later, proliferation of fibroblasts at the injured site occurs. These cells differentiate into contractile myofibroblasts, which are the source of cellular soft tissue contraction. Following cellular contraction, collagen is laid down as a static supporting matrix in the tightened soft tissue structure. The deposition and subsequent remodeling of this nascent scar matrix provides the means to alter the consistency and geometry of soft tissue for aesthetic purposes.

[0013] In light of the preceding discussion, there are a number of dermatological procedures that lend themselves to treatments which deliver thermal energy to the skin and underlying tissue to cause a contraction of collagen, and/or initiate a would healing response. Such procedures include skin remodeling/resurfacing, wrinkle removal, and treatment of the sebaceous glands, hair follicles adipose tissue and spider veins.

[0014] Currently available technologies that deliver thermal energy to the skin and underlying tissue include Radio Frequency (RF), optical (laser) and other forms of electromagnetic energy as well as ultrasound and direct heating with a hot surface. However, these technologies have a number of technical limitations and clinical issues which limit the effectiveness of the treatment and/or preclude treatment altogether.

[0015] These issues include the following: i) achieving a uniform thermal effect across a large area of tissue, ii) controlling the depth of the thermal effect to target selected tissue and prevent unwanted thermal damage to both target and non-target tissue, iii) reducing adverse tissue effects such as burns, redness blistering, iv) replacing the practice of delivery energy/treatment in a patchwork fashion with a more continuous delivery of treatment (e.g. by a sliding or painting motion), v) improving access to difficult-to-reach areas of the skin surface and vi) reducing procedure time and number of patient visits required to complete treatment. As will be discussed herein the current invention provides an apparatus for solving these and other limitations.

[0016] One of the key shortcomings of currently available RF technology for treating the skin is the edge effect phenomenon. In general, when RF energy is being applied or delivered to tissue through an electrode which is in contact with that tissue, the current concentrate around the edges of the electrode, sharp edges in particular. This effect is generally known as the edge effect. In the case of a circular disc electrode, the effect manifests as a higher current density around the perimeter of that circular disc and a relatively low current density in the center. For a square-shaped electrode there is typically a high current density around the entire perimeter, and an even higher current density at the corners.

[0017] Edge effects cause problems in treating the skin for several reasons. First, they result in a non-uniform thermal effect over the electrode surface. In various treatments of the skin, it is important to have a uniform thermal effect over a relatively large surface area, particularly for dermatological treatments. Large in this case being on the order of several square millimeters or even several square centimeters. In electrosurgical applications for cutting tissue, there typically is a point type applicator designed with the goal of getting a hot spot at that point for cutting or even coagulating tissue. However, this point design is undesirable for creating a reasonably gentle thermal effect over a large surface area. What is needed is an electrode design to deliver uniform thermal energy to skin and underlying tissue without hot spots.

[0018] A uniform thermal effect is particularly important when cooling is combined with heating in skin/tissue treatment procedure. As is discussed below, a non-uniform thermal pattern makes cooling of the skin difficult and hence the resulting treatment process as well. When heating the skin with RF energy, the tissue at the electrode surface tends to be warmest with a decrease in temperature moving deeper into the tissue. One approach to overcome this thermal gradient and create a thermal effect at a set distance away from the electrode is to cool the layers of skin that are in contact with the electrode. However, cooling of the skin is made difficult if there is a non-uniform heating pattern.

[0019] If the skin is sufficiently cooled such that there are no burns at the corners of a square or rectangular electrode, or at the perimeter of a circular disc electrode, then there will probably be overcooling in the center and there won't be any significant thermal effect (i.e. tissue heating) under the center of the electrode. Contrarily, if the cooling effect is decreased to the point where there is a good thermal effect in the center of the electrode, then there probably will not be sufficient cooling to protect tissue in contact with the edges of the electrode. As a result of these limitations, in the typical application of a standard electrode there is usually an area of non-uniform treatment and/or burns on the skin surface. So uniformity of the heating pattern is very important. It is particularly important in applications treating skin where collagen-containing layers are heated to produce a collagen contraction response for tightening of the skin. For this and related applications, if the collagen contraction and resulting skin tightening effect are nonuniform, then a medically undesirable result may occur.

[0020] There is a need for improved methods for creating tissue effects using electromagnetic energy and a reverse thermal gradient. There is a further need for methods that create tissue effects with reverse thermal gradients which induce the formation of collagen. Yet there is a further need for methods that create tissue effects which use RF electrodes and reverse thermal gradients.

SUMMARY OF THE INVENTION

[0021] Accordingly, an object of the present invention is to provide methods for creating tissue effects utilizing reverse thermal gradients and electromagnetic energy.

[0022] Another object of the present invention is to provide methods for creating tissue effects utilizing RF energy.

[0023] Yet another object of the present invention is to provide methods for creating tissue effects utilizing electromagnetic energy with different amounts of cooling applied to a skin surface before, during and after treatment.

[0024] A further object of the present invention is to provide methods for creating tissue effects utilizing electromagnetic energy and information stored in a memory that facilitates operation an electromagnetic energy delivery device, a cooling device or an electromagnetic energy source.

[0025] These and other objects of the present invention are achieved in a method of creating a tissue effect at a tissue site. Electromagnetic energy is delivered through a skin surface from an electromagnetic energy delivery device coupled to an electromagnetic energy source. At least one of the electromagnetic energy delivery device or electromagnetic energy source includes a memory. A reverse thermal gradient is created through the skin surface to sufficiently heat an underlying tissue site to provide that a temperature of the skin surface is lower than a temperature of the underlying tissue. Information is stored from the memory to facilitate operation of at least one of the electromagnetic energy delivery device or the electromagnetic energy source. Electromagnetic energy is applied through the skin surface to the underlying tissue. A tissue effect is created on at least a portion of the tissue site.

[0026] In another embodiment of the present invention, a method of creating a tissue effect at a tissue site provides an electromagnetic energy delivery device. Electromagnetic energy is delivered through a skin surface. A reverse thermal gradient is created through the skin surface to sufficiently heat an underlying tissue to provide that a temperature of the skin surface is lower than a temperature of the underlying tissue. A temperature of the skin surface is detected. The external skin surface and underlying tissue are heated in response to a detected temperature of the skin surface. A tissue effect is created on at least a portion of the tissue site.

[0027] In another embodiment of the present invention, a method for creating a tissue effect at a tissue site provides an RF energy delivery device with an energy delivery surface. The RF energy delivery surface is coupled with a skin surface. A reverse thermal gradient is created through the skin surface to sufficiently heat an underlying tissue, and a temperature of the skin surface is lower than a temperature of the underlying tissue. A temperature of the skin surface is detected. The skin surface and underlying tissue are heated in response to a detected temperature of the external surface of the skin. A tissue effect is created on at least a portion of the tissue site.

[0028] In another embodiment of the present invention, a method of creating a tissue effect provides an electromagnetic energy source. A temperature of at least a portion of a skin surface is reduced to provide that the temperature of the skin surface is less than the temperature of an underlying tissue. Energy is delivered non-continuously through the skin surface to the underlying tissue. A tissue effect is created on at least a portion of the underlying tissue.

[0029] In another embodiment of the present invention, a method of creating a tissue effect provides an electromagnetic energy source. A temperature of at least a portion of a skin surface is non-continuously reduced a temperature, to provide that the temperature of the skin surface is less than the temperature of an underlying tissue. A tissue effect is created on at least a portion of the underlying tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

[0030]FIG. 1(a) is a cross-sectional view of one embodiment of the handpiece of the present invention.

[0031]FIG. 1(b) is a cross-sectional view of another embodiment of the RF device with a thermoelectric cooler.

[0032]FIG. 2 is an exploded view of the FIG. 1 RF electrode assembly.

[0033]FIG. 3(a) is a close-up view of one embodiment of an RF electrode of the present invention.

[0034]FIG. 3(b) illustrates one embodiment of an RF electrode, that can be utilized with the present invention, with an outer edge geometry configured to reduce an amount of capacitively coupled area the outer edge.

[0035]FIG. 3(c) illustrates an one embodiment of an RF electrode, that can be utilized with the present invention, that has voids where there is little if any conductive material.

[0036]FIG. 4 is a cross-sectional view of the RF electrode assembly from FIG. 1.

[0037]FIG. 5 is a side view of one embodiment of an RF handpiece assembly of the present invention.

[0038]FIG. 6 is a rear view of the FIG. 5 RF electrode assembly.

[0039]FIG. 7 is a flow chart that illustrates one embodiment of a ready state of a handpiece and its associated electromagnetic energy source (the “System”).

[0040]FIG. 8 is a flow chart that illustrates one embodiment of an armed state of the System.

[0041]FIG. 9 is a flow chart that illustrates one embodiment of an active state of the System.

[0042]FIG. 10 is a flow chart that illustrates one embodiment of a main control loop that can be utilized with the present invention.

[0043]FIG. 11 is a flow chart that illustrates how the System of the present invention can check the channels of the associated sensors utilized with the present invention.

[0044]FIG. 12 is a flow chart that illustrates one embodiment of an active state of the System.

[0045]FIG. 13 is a flow chart that illustrates one embodiment of checking a support structure of the present invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0046] In various embodiments, the present invention provides methods for treating a tissue site. In one embodiment, an energy delivery surface of an energy delivery device is coupled to a skin surface. The coupling can be a direct, in contact, placement of the energy delivery surface of the energy delivery on the skin surface, or distanced relationship between the two with our without a media to conduct energy to the skin surface from the energy delivery surface of the energy delivery device. The skin surface is cooled sufficiently to create a reverse thermal gradient where a temperature of the skin surface is less than an underlying tissue. Energy is delivered from the energy delivery device to the underlying tissue area, resulting in a tissue effect at the skin surface.

[0047] Referring now to FIG. 1(a), the methods of present invention can be achieved with the use of a handpiece 10. Handpiece 10 is coupled with a handpiece assembly 12 that includes a handpiece housing 14 and a cooling fluidic medium valve member 16. Handpiece housing 14 is configured to be coupled to a suitable electromagnetic energy delivery device, including but not limited to an electrode assembly 18. Electrode assembly 18 has a least one RF electrode 20 that is capacitively coupled to a skin surface when at least a portion of RF electrode 20 is in contact with the skin surface. Without limiting the scope of the present invention, RF electrode 20 can have a thickness in the range of 0.010 to 1.0 mm.

[0048] Handpiece 10 provides a more uniform thermal effect in tissue at a selected depth, while preventing or minimizing thermal damage to the skin surface and other non-target tissue. Handpiece 10 is coupled to an electromagnetic energy source, including but not limited to an RF generator, creating at least a portion of the System. RF electrode 20 can be operated either in mono-polar or bi-polar modes. Handpiece 10 is configured to reduce, or preferably eliminate edge effects and hot spots. The result is an improved aesthetic result/clinical outcome with an elimination/reduction in adverse effects and healing time.

[0049] A fluid delivery member 22 is coupled to cooling fluidic medium valve member 16. Fluid delivery member 22 and cooling fluidic medium valve member 16 collectively form a cooling fluidic medium dispensing assembly. Fluid delivery member 22 is configured to provide an atomizing delivery of a cooling fluidic medium to RF electrode 20. The atomizing delivery is a mist or fine spray. A phase transition, from liquid to gas, of the cooling fluidic medium occurs when it hits the surface of RF electrode 20. The transition from liquid to gas creates the cooling. If the transition before the cooling fluidic medium hits RF electrode 20 the cooling of RF electrode 20 will not be as effective.

[0050] In another embodiment, illustrated in FIG. 1(b), a thermo-electric cooler 23 is utilized in place of cooling fluidic medium valve member 16 and fluid delivery member 22.

[0051] In one embodiment, the cooling fluidic medium is a cryogenic spray, commercially available from Honeywell, Morristown, N.J. A specific example of a suitable cryogenic spray is R134A₂, available from Refron, Inc., 38-18 33^(rd) St,, Long Island City, N.Y. 11101. The use of a cryogenic cooling fluidic medium provides the capability to use a number of different types of algorithms for skin treatment. For example, the cryogenic cooling fluidic medium can be applied milliseconds before and after the delivery of RF energy to the desired tissue. This is achieved with the use of cooling fluidic medium valve member 16 coupled to a cryogen supply, including but not limited to a compressed gas canister. In various embodiments, cooling fluidic medium valve member 16 can be coupled to a computer control system and/or manually controlled by the physician by means of a foot switch or similar device.

[0052] Providing a spray, or atomization, of cryogenic cooling fluidic medium is particularly suitable because of it provides an availability to implement rapid on and off control. Cryogenic cooling fluidic medium allows more precise temporal control of the cooling process. This is because cooling only occurs when the refrigerant is sprayed and is in an evaporative state, the latter being a very fast short-lived event. Thus, cooling ceases rapidly after the cryogenic cooling fluidic medium is stopped. The overall effect is to confer very precise time on-off control of cryogenic cooling fluidic medium.

[0053] Referring now to FIG. 2, fluid delivery member 22 and thermo-electric cooler 23 can be positioned in handpiece housing 14 or electrode assembly 18. Fluid delivery member 22 is configured to controllably deliver a cooling fluidic medium. Fluid delivery member 22 and thermo-electric cooler 23 cool a back surface 24 of RF electrode 20 and maintain back surface 24 at a desired temperature. The cooling fluidic medium evaporatively cools RF electrode 20 and maintains a substantially uniform temperature of front surface 26 of RF electrode 20. Fluid delivery member 22 evaporatively cools back surface 24. Front surface 26 may or may not be flexible and conformable to the skin, but it will still have sufficient strength and/or structure to provide good thermal coupling when pressed against the skin surface.

[0054] RF electrode 20 then conductively cools a skin surface that is adjacent to a front surface 26 of RF electrode 20. Suitable fluidic media include a variety of refrigerants such as R134A and freon.

[0055] Fluid delivery member 22 is configured to controllably deliver the cooling fluidic medium to back surface 24 at substantially any orientation of front surface 26 relative to a direction of gravity. A geometry and positioning of fluid delivery member 22 is selected to provide a substantially uniform distribution of cooling fluidic medium on back surface 24. The delivery of the cooling fluidic medium can be by spray of droplets or fine mist, flooding back surface 24, and the like. Cooling occurs at the interface of the cooling fluidic medium with atmosphere, which is where evaporation occurs. If there is a thick layer of fluid on back surface 24 the heat removed from the treated skin will need to pass through the thick layer of cooling fluidic medium, increasing thermal resistance. To maximize cooling rates, it is desirable to apply a very thin layer of cooling fluidic medium. If RF electrode 20 is not horizontal, and if there is a thick layer of cooling fluidic medium, or if there are large drops of cooling fluidic medium on back surface 24, the cooling fluidic medium can run down the surface of RF electrode 20 and pool at one edge or corner, causing uneven cooling. Therefore, it is desirable to apply a thin layer of cooling fluidic medium with a fine spray. Thermo-electric cooler 23 achieves these same results but without delivering a cooling medium. Thermo-electric cooler 23 is cold on the side that is adjacent to or in contact with surface 24, while its opposing side becomes warmer.

[0056] In various embodiments, RF electrode 20, as illustrated in FIG. 3(a), has a conductive portion 28 and a dielectric portion 30. Conductive portion 28 can be a metal including but not limited to copper, gold, silver, aluminum and the like. Dielectric portion 30 can be made of a variety of different materials including but not limited to polyimide, Teflon® and the like, silicon nitride, polysilanes, polysilazanes, polyimides, Kapton and other polymers, antenna dielectrics and other dielectric materials well known in the art. Other dielectric materials include but are not limited to polymers such as polyester, silicon, sapphire, diamond, zirconium-toughened alumina (ZTA), alumina and the like. Dielectric portion 30 can be positioned around at least a portion, or the entirety of a periphery of conductive portion 28. In another embodiment, RF electrode 20 is made of a composite material, including but not limited to gold-plated copper, copper-polyimide, silicon/silicon-nitride and the like.

[0057] Dielectric portion 30 creates an increased impedance to the flow of electrical current through RF electrode 20. This increased impedance causes current to travel a path straight down through conductive portion 28 to the skin surface. Electric field edge effects, caused by a concentration of current flowing out of the edges of RF electrode 20, are reduced.

[0058] Dielectric portion 30 produces a more uniform impedance through RF electrode 20 and causes a more uniform current to flow through conductive portion 28. The resulting effect minimizes or even eliminates, edge effects around the edges of RF electrode 20. As shown in FIG. 3(c), RF electrode 20 can have voids 33 where there is little or no conductive material. Creating voids 33 in the conductive material alters the electric field. The specific configuration of voids can be used to minimize edge effect, or alter the depth, uniformity or shape of the electric field. Under a portion 28′ of the RF electrode 20 with solid conductive material the electric field is deeper. Under a portion 28″ of RF electrode 20 with more voids, the electric field is shallower. By combining different densities of conductive material, an RF electrode 20 is provided to match the desired heating profile.

[0059] In one embodiment, conductive portion 28 adheres to dielectric portion 30 which can be a substrate with a thickness, by way of example and without limitation, of about 0.001″. This embodiment is similar to a standard flex circuit board material commercially available in the electronics industry. In this embodiment, dielectric portion 30 is in contact with the tissue, the skin, and conductive portion 28 is separated from the skin.

[0060] The thickness of the dielectric portion 30 can be decreased by growing conductive portion 28 on dielectric portion 30 using a variety of techniques, including but not limited to, sputtering, electro deposition, chemical vapor deposition, plasma deposition and other deposition techniques known in the art. Additionally, these same processes can be used to deposit dielectric portion 30 onto conductive portion 28. In one embodiment dielectric portion 30 is an oxide layer which can be grown on conductive portion 28. An oxide layer has a low thermal resistance and improves the cooling efficiency of the skin compared with many other dielectrics such as polymers.

[0061] In various embodiments, RF electrode 20 is configured to inhibit the capacitive coupling to tissue along its outside edge 31. Referring to FIG. 3(b) RF electrode 20 can have an outer edge 31 with a geometry that is configured to reduce an amount of capacitively coupled area at outer edge 31. Outer edge 31 can have less of the conductive portion 28 material. This can be achieved by different geometries, including but not limited to a scalloped geometry, and the like. The total length of outer edge 31 can be increased, with different geometries, and the total area that is capacitively coupled to tissue is reduced. This produces a reduction in energy generation around outer edge 31.

[0062] Alternatively, the dielectric material can be applied in a thicker layer at the edges, reducing the electric field at the edges. A further alternative is to configure the cooling to cool more aggressively at the edges to compensate for any electric field edge effect.

[0063] Fluid delivery member 22 has an inlet 32 and an outlet 34. Outlet 34 can have a smaller cross-sectional area than a cross-sectional area of inlet 32. In one embodiment, fluid delivery member 22 is a nozzle 36.

[0064] Cooling fluidic medium valve member 16 can be configured to provide a pulsed delivery of the cooling fluidic medium. Pulsing the delivery of cooling fluidic medium is a simple way to control the rate of cooling fluidic medium application. In one embodiment, cooling fluidic medium valve member 16 is a solenoid valve. An example of a suitable solenoid valve is a solenoid pinch valve manufactured by the N-Research Corporation, West Caldwell, N.J. If the fluid is pressurized, then opening of the valve results in fluid flow. If the fluid is maintained at a constant pressure, then the flow rate is constant and a simple open/close solenoid valve can be used, the effective flow rate being determined by the pulse duty cycle. A higher duty cycle, close to 100% increases cooling, while a lower duty cycle, closer to 0%, reduces cooling. The duty cycle can be achieved by turning on the valve for a short duration of time at a set frequency. The duration of the open time can be 1 to 50 milliseconds or longer. The frequency of pulsing can be 1 to 50 Hz or faster.

[0065] Alternatively, cooling fluidic medium flow rate can be controlled by a metering valve or controllable-rate pump such as a peristaltic pump. One advantage of pulsing is that it is easy to control using simple electronics and control algorithms.

[0066] Electrode assembly 18 is sufficiently sealed so that the cooling fluidic medium does not leak from back surface 24 onto a skin surface in contact with a front surface of RF electrode 20. This helps provide an even energy delivery through the skin surface. In one embodiment, electrode assembly 18, and more specifically RF electrode 20, has a geometry that creates a reservoir at back surface 24 to hold and gather cooling fluidic medium that has collected at back surface 24. Back surface 24 can be formed with “hospital corners” to create this reservoir. Optionally, electrode assembly 18 includes a vent that permits vaporized cooling fluidic medium to escape from electrode assembly 18.

[0067] The vent prevents pressure from building up in electrode assembly 18. The vent can be a pressure relief valve that is vented to the atmosphere or a vent line. When the cooling fluidic medium comes into contact with RF electrode 20 and evaporates, the resulting gas pressurizes the inside of electrode assembly 18. This can cause RF electrode 20 to partially inflate and bow out from front surface 26. The inflated RF electrode 20 can enhance the thermal contact with the skin and also result in some degree of conformance of RF electrode 20 to the skin surface. An electronic controller can be provided. The electronic controller sends a signal to open the vent when a programmed pressure has been reached.

[0068] Various leads 40 are coupled to RF electrode 20. One or more thermal sensors 42 are coupled to RF electrode. If will be appreciated that other sensors, including but not limited to voltage, current, power and the like, can also be included. Suitable thermal sensors 42 include but are not limited to thermocouples, thermistors, infrared photo-emitters and a thermally sensitive diode. In one embodiment, a thermal sensor 42 is positioned at each corner of RF electrode 20. A sufficient number of thermal sensors 42 are provided in order to acquire sufficient thermal data of the skin surface or the back surface 24 of the electrode 20. Thermal sensors 42 are electrically isolated from RF electrode 20. In another embodiment, at least one sensor 42 is positioned at back surface 24 of RF electrode and detects the temperature of back surface 24 in response to the delivery of cooling fluidic medium.

[0069] Thermal sensors 42 measure temperature and can provide feedback for monitoring temperature of RF electrode 20 and/or the tissue during treatment.. Thermal sensors 42 can be thermistors, thermocouples, thermally sensitive diodes, capacitors, inductors or other devices for measuring temperature. Preferably, thermal sensors 42 provide electronic feedback to a microprocessor of the RF generator coupled to RF electrode 20 in order to facilitate control of the treatment.

[0070] Measurements from thermal sensors 42 can be used to help control the rate of application of cooling fluidic medium. For example, a cooling control algorithm can be used to apply cooling fluidic medium to RF electrode 20 at a high flow rate until the temperature fell below a target temperature, and then slow down or stop. A PID, or proportional-integral-differential, algorithm can be used to precisely control RF electrode 20 temperature to a predetermined value.

[0071] Thermal sensors 42 can be positioned on back surface 24 of RF electrode 20 away from the tissue. This configuration is preferable for controlling the temperature of the RF electrode 20. Alternatively, thermal sensors 42 can be positioned on front surface 26 of RF electrode 10 in direct contact with the tissue. This embodiment can be more suitable for monitoring tissue temperature. Algorithms are utilized with thermal sensors 42 to calculate a temperature profile of the treated tissue. Thermal sensors 42 can be used to develop a temperature profile of the skin which is then used for process control purposes to assure that the proper amounts of heating and cooling are delivered to achieve a desired elevated deep tissue temperature while maintaining skin tissue layers below a threshold temperature and avoid thermal injury.

[0072] The physician can use the measured temperature profile to assure that he stays within the boundary of an ideal/average profile for a given type of treatment. Thermal sensors 42 can be used for additional purposes. When the temperature of thermal sensors 42 is monitored it is possible to detect when RF electrode 20 is in contact with the skin surface. This can be achieved by detecting a direct change in temperature when skin contact is made or examining the rate of change of temperature which is affected by contact with the skin. Similarly, if there is more than one thermal sensor 42, the thermal sensors 42 can be used to detect whether a portion of RF electrode 20 is lifted or out of contact with skin. This can be important because the current density (amperes per unit area) delivered to the skin can vary if the contact area changes. In particular, if part of the surface of RF electrode 20 is not in contact with the skin, the resulting current density is higher than expected.

[0073] Referring again to FIG. 1(a), a force sensor 44 is also coupled to electrode assembly 18. Force sensor 44 detects an amount of force applied by electrode assembly 18, via the physician, against an applied skin surface. Force sensor 44 zeros out gravity effects of the weight of electrode assembly 18 in any orientation of front surface 26 of RF electrode 20 relative to a direction of gravity. Additionally, force sensor 44 provides an indication when RF electrode 20 is in contact with a skin surface. Force sensor 44 also provides a signal indicating that a force applied by RF electrode 20 to a contacted skin surface is, (i) above a minimum threshold or (ii) below a maximum threshold.

[0074] As illustrated in FIG. 4, an activation button 46 is used in conjunction with the force sensor. Just prior to activating RF electrode 20, the physician holds handpiece 10 in position just off the surface of the skin. The orientation of handpiece 10 can be any angle relative to the direction of gravity. To arm handpiece 10, the physician can press activation button 46 which tares force sensor 44, by setting it to read zero. This cancels the force due to gravity in that particular treatment orientation. This method allows consistent force application of RF electrode 20 to the skin surface regardless of the angle of handpiece 10 relative to the direction of gravity.

[0075] RF electrode 20 can be a flex circuit, which can include trace components. Additionally, thermal sensor 42 and force sensor 44 can be part of the flex circuit. Further, the flex circuit can include a dielectric that forms a part of RF electrode 20.

[0076] Electrode assembly 18 can be moveably positioned within handpiece housing 12. In one embodiment, electrode assembly 18 is slideably moveable along a longitudinal axis of handpiece housing 12.

[0077] Electrode assembly 18 can be rotatably mounted in handpiece housing 12. Additionally, RF electrode 20 can be rotatably positioned in electrode assembly 18. Electrode assembly 18 can be removably coupled to handpiece housing 12 as a disposable or non-disposable RF device 52.

[0078] For purposes of this disclosure, electrode assembly 18 is the same as RF device 52. Once movably mounted to handpiece housing 12, RF device 52 can be coupled to handpiece housing 12 via force sensor 44. Force sensor 44 can be of the type that is capable of measuring both compressive and tensile forces. In other embodiments, force sensor 44 only measures compressive forces, or only measures tensile forces.

[0079] RF device 52 can be spring-loaded with a spring 48. In one embodiment, spring 48 biases RF electrode 20 in a direction toward handpiece housing 12. This pre-loads force sensor 44 and keeps RF device 52 pressed against force sensor 44. The pre-load force is tared when activation button 46 is pressed just prior to application of RF electrode 20 to the skin surface.

[0080] A shroud 50 is optionally coupled to handpiece 10. Shroud 50 serves to keep the user from touching RF device 52 during use which can cause erroneous force readings.

[0081] A memory 54 can be included with RF device 52. Memory 54 can be an EPROM and the like. Additionally, a second non-volatile memory can be included in handpiece housing 12 for purposes of storing handpiece 10 information such as but not limited to, handpiece model number or version, handpiece software version, number of RF applications that handpiece 10 has delivered, expiration date and manufacture date. Handpiece housing 12 can also contain a microprocessor 58 for purposes of acquiring and analyzing data from various sensors on handpiece housing 12 or RF device 52 including but not limited to thermal sensors 42, force sensors 44, fluid pressure gauges, switches, buttons and the like.

[0082] Microprocessor 58 can also control components on handpiece 10 including but not limited to lights, LEDs, valves, pumps or other electronic components. Microprocessor 58 can also communicate data to a microprocessor of the RF generator.

[0083] Memory 54 can be utilized to assist in a variety of different functions including but not limited to, (i) controlling an amount of current delivered by RF electrode 20, (ii) controlling energy delivery duration time of RF electrode 20, (iii) controlling a temperature of RF electrode 20 relative to a target temperature, (iv) providing a maximum number of firings of RF electrode 20, (v) providing a maximum allowed voltage that is deliverable by RF electrode 20, (vi) a history of RF electrode 20 use, (vii) a controllable duty cycle to fluid delivery member 22, (viii) providing a controllable delivery rate of cooling media delivered from fluid delivery member 22, (ix) providing an amount of time that RF electrode 20 can be used, (x) providing an amount of RF electrode 20 usage, (xi) providing a number of areas treated by RF electrode 20, (xii) providing a number of times RF electrode 20 has been moved relative to the skin surface, (xiii) providing time or date of RF electrode 20 usage, (xiv) providing a thickness of the stratum corneum, (xv) providing an amount of energy delivered by RF electrode 20, (xvi) providing a status of RF electrode 20, (xvii) providing a status of RF generator, (xviii) providing information relative to a change of tissue in response to energy delivered by RF electrode 20, (xix) providing status information of fluid delivery member 22, (xx) providing temperature information relative to fluid delivery member, (xxi) providing temperature information relative to thermoelectric cooler 23, and the like.

[0084] Referring now to FIGS. 5 and 6, RF device 52 includes a support structure 60, including but not limited to a housing 60 that defines the body of RF device 52. RF device 52 can include a back plate 62 that is positioned at a proximal portion of support structure 60. A plurality of electrical contact pads 64 can be positioned at back plate 62. At least a portion of fluid delivery member 22 and thermoelectric cooler 23 can extend through back plate 62. Fluid delivery member 22 can be a channel with a proximal end that is raised above the back surface of back plate 62.

[0085] First and second engagement members 64 can also be formed in the body of support structure 60. Engagement members 64 provide engagement and disengagement with handpiece housing 14. Suitable engagement members 64 include but are not limited to snap members, apertures to engage with snap members of support structure 60, and the like.

[0086] Handpiece 10 can be used to deliver thermal energy to modify tissue including, but not limited to, collagen containing tissue, in the epidermal, dermal and subcutaneous tissue layers, including adipose tissue. The modification of the tissue includes modifying a physical feature of the tissue, a structure of the tissue or a physical property of the tissue. The modification can be achieved by delivering sufficient energy to modify collagen containing tissue, cause collagen shrinkage, and/or a wound healing response including the deposition of new or nascent collagen, and the like.

[0087] Handpiece 10 can be utilized for performing a number of treatments of the skin and underlying tissue including but not limited to, (i) dermal remodeling and tightening, (ii) wrinkle reduction, (iii) elastosis reduction, (iv) scar reduction, (v) sebaceous gland removal/deactivation and reduction of activity of sebaceous gland, (vi) hair follicle removal, (vii) adipose tissue remodeling/removal, (viii) spider vein removal, (ix) modify contour irregularities of a skin surface, (x) create scar or nascent collagen, (xi) reduction of bacteria activity of skin, (xii) reduction of skin pore size, (xiii) unclog skin pores and the like.

[0088] In various embodiments, handpiece 10 can be utilized in a variety of treatment processes, including but not limited to, (i) pre-cooling, before the delivery of energy to the tissue has begun, (ii) an on phase or energy delivery phase in conjunction with cooling and (iii) post cooling after the delivery of energy to tissue has stopped. Thus, in various embodiments, cooling can be delivered at different rates, e.g., during treatment phases, before, during and after delivery of the energy to the tissue site.

[0089] In one embodiment, at least a portion of the tissue site is photographed before the tissue site treatment by the System under a first set of conditions. At some time after the tissue site treatment is completed, at least a portion of the treatment site is photographed under substantially the same conditions as those of the first set of conditions.

[0090] Handpiece 10 can be used to pre-cool the surface layers of the target tissue so that when RF electrode 20 is in contact with the tissue, or prior to turning on the RF energy source, the superficial layers of the target tissue are already cooled. When RF energy source is turned on or delivery of RF to the tissue otherwise begins, resulting in heating of the tissues, the tissue that has been cooled is protected from thermal effects including thermal damage. The tissue that has not been cooled will warm up to therapeutic temperatures resulting in the desired therapeutic effect.

[0091] Pre-cooling gives time for the thermal effects of cooling to propagate down into the tissue. More specifically, pre-cooling allows the achievement of a desired tissue depth thermal profile, with a minimum desired temperature being achieved at a selectable depth. The amount or duration of pre-cooling can be used to select the depth of the protected zone of untreated tissue. Longer durations of pre-cooling produce a deeper protected zone and hence a deeper level in tissue for the start of the treatment zone. The opposite is true for shorter periods of pre-cooling. The temperature of front surface 26 of RF electrode 20 also affects the temperature profile. The colder the temperature of front surface 26, the faster and deeper the cooling, and vice verse.

[0092] Post-cooling can be important because it prevents and/or reduces heat delivered to the deeper layers from conducting upward and heating the more superficial layers possibly to therapeutic or damaging temperature range even though external energy delivery to the tissue has ceased. In order to prevent this and related thermal phenomena, it can be desirable to maintain cooling of the treatment surface for a period of time after application of the RF energy has ceased. In various embodiments, varying amounts of post cooling can be combined with real-time cooling and/or pre-cooling.

[0093] In various embodiments, handpiece 10 can be used in a varied number of pulse on-off type cooling sequences and algorithms may be employed. In one embodiment, the treatment algorithm provides for pre-cooling of the tissue by starting a spray of cryogenic cooling fluidic medium, followed by a short pulse of RF energy into the tissue. In this embodiment, the spray of cryogenic cooling fluidic medium continues while the RF energy is delivered, and is stopping shortly thereafter, e.g. on the order of milliseconds. This or another treatment sequence can be repeated again. Thus in various embodiments, the treatment sequence can include a pulsed sequence of cooling on, heat, cooling off, cooling on, heat, cool off, and with cooling and heating durations on orders of tens of milliseconds. In these embodiments, every time the surface of the tissue of the skin is cooled, heat is removed from the skin surface. Cryogenic cooling fluidic medium spray duration, and intervals between sprays, can be in the tens of milliseconds ranges, which allows surface cooling while still delivering the desired thermal effect into the deeper target tissue.

[0094] In various embodiments, the target tissue zone for therapy, also called therapeutic zone or thermal effect zone, can be at a tissue depth from approximately 100 μm beneath the surface of the skin down to as deep as 10 millimeters, depending upon the type of treatment. For treatments involving collagen contraction, it can be desirable to cool both the epidermis and the superficial layers of the dermis of the skin that lies beneath the epidermis, to a cooled depth range between 100 μm two millimeters. Different treatment algorithms can incorporate different amounts of pre-cooling, heating and post cooling phases in order to produce a desired tissue effect at a desired depth.

[0095] Various duty cycles, on and off times, of cooling and heating are utilized depending on the type of treatment. The cooling and heating duty cycles can be controlled and dynamically varied by an electronic control system known in the art. Specifically the control system can be used to control cooling fluidic medium valve member 16 and the RF power source.

[0096] In one embodiment, handpiece 10 is utilized in a variety of different states, including but not limited to, ready, armed, active, standby and the like. The ready state is illustrated in FIG. 7, where in one embodiment memory 54 is checked to see in the maximum treatment and/or the maximum number of treatments has been exceeded. If so, then there is an error state and a signal is provide to the physician. If neither one has been exceeded, and activation button 46 has not been pressed, then there is a wait until activation button 46, or an associated footswitch, is activated. It either one is activated, then the System proceeds to the armed state.

[0097] In the armed state, shown in FIG. 8, an armed tone can be provided, and in one embodiment three seconds are allowed for the physician to cause handpiece 10 to become coupled to a skin surface, which can be direct physical contact with the skin surface of the patient. If more than the allotted time has passed, then the System is in an error state. Force sensor 44 is used to determine when there is contact by handpiece 10 with the patient. If there is the proper amount of force applied by handpiece 10, then there is a transition to the active state.

[0098] As illustrated in FIG. 9, the active begins when there is actual contact by handpiece 10 with the patient. A pre-cool is first applied to the skin surface. Electromagnetic energy, such as RF, is then delivered. If activation button 46 is released a tone or other indicator can go off and the System is again in an error state. This can occur at any time. Following delivery of electromagnetic energy, there is a post cooling state. The levels of cooling delivered to the skin surface at pre-cooling, during electromagnetic energy delivery, and post-cooling, can each be different.

[0099]FIG. 10 illustrates an embodiment where a main control loop is provided that self tests the System. Following the self test, there is an initialization of the System, followed by a fine tuning, and then the System is prepared for the ready state.

[0100] As illustrated in FIG. 11, all channels from the sensors, including but not limited to voltage, current power, temperature, and the like, are read. An updated set of current values is created. Checks are then made, as illustrated in FIG. 12, to make sure that handpiece 10 is connected to the electromagnetic energy source, and that the particular handpiece 10 is a valid one suitable for use with the electromagnetic energy source. A check is also made that support structure 60 is connected and also valid, e.g., that the support structure 60 is a suitable for use with handpiece 10 and the electromagnetic energy source. The parameters of a treatment tip associated with support structure are then updated, followed by transition to the ready state when activation button 46 or the footswitch is depressed.

[0101] Referring now to FIG. 13, support structure is checked to make sure that it is connected. The CRC of a memory code of memory 54 is also checked. Checks are also made to make sure that the electromagnetic energy source, and handpiece 10 are acceptable devices. If there is expiration of any of the devices, including but not limited to support structure 60, or a device is not acceptable, the System is in an error state.

[0102] The foregoing description of a preferred embodiment of the invention has been presented for purposes of illustration and description. It is not intended to be exhaustive or to limit the invention to the precise forms disclosed. Obviously, many modifications and variations will be apparent to practitioners skilled in this art. It is intended that the scope of the invention be defined by the following claims and their equivalents. 

What is claimed is:
 1. A method of creating a tissue effect at a tissue site, comprising: delivering electromagnetic energy through a skin surface from an electromagnetic energy delivery device coupled to an electromagnetic energy source, at least one of the electromagnetic energy delivery device or electromagnetic energy source including a memory; creating a reverse thermal gradient through the skin surface to sufficiently heat an underlying tissue site, wherein a temperature of the skin surface is lower than a temperature of the underlying tissue; storing information from a memory coupled to facilitate operation of at least one of the electromagnetic energy delivery device or the electromagnetic energy source; applying electromagnetic energy through the skin surface to the underlying tissue; and creating a tissue effect on at least a portion of the tissue site.
 2. The method of claim 1, wherein the tissue effect is dermal remodeling.
 3. The method of claim 1, wherein the tissue effect is dermal tightening.
 4. The method of claim 1, wherein the tissue effect is wrinkle reduction.
 5. The method of claim 1, wherein the tissue effect is elastosis reduction.
 6. The method of claim 1, wherein the tissue effect is scar reduction.
 7. The method of claim 1, wherein the tissue effect is sebaceous gland removal or deactivation.
 8. The method of claim 1, wherein the tissue effect is a reduction of sebaceous gland activity
 9. The method of claim 1, wherein the tissue effect is hair follicle modification.
 10. The method of claim 1, wherein the tissue effect is adipose tissue remodeling or removal.
 11. The method of claim 1, wherein the tissue effect is spider vein removal
 12. The method of claim 1, wherein the tissue effect is modification of skin irregularities
 13. The method of claim 1, wherein the tissue effect is a creation of scar or nascent collagen
 14. The method of claim 1, wherein the tissue effect is a reduction of skin bacteria activity.
 15. The method of claim 1, wherein the tissue effect is a modification of skin pore size.
 16. The method of claim 1, wherein the tissue effect is an unclogging of skin pores.
 17. The method of claim 1, wherein the tissue effect is a modification of fat tissue.
 18. The method of claim 1, wherein the tissue effect is a modification of muscle tissue.
 19. The method of claim 1, wherein the tissue effect is a modification of facial tissue.
 17. The method of claim 1, wherein the stored information is utilized to assist in controlling an amount of energy delivered from the electromagnetic energy device
 18. The method of claim 1, wherein the stored information is utilized to assist in controlling energy delivery duration time of the electromagnetic energy delivery device.
 19. The method of claim 1, wherein the stored information is utilized to assist in controlling a temperature of the electromagnetic energy delivery device relative to a target temperature
 20. The method of claim 1, wherein the stored information is utilized to assist in providing a maximum number of firings of the electromagnetic energy delivery device.
 21. The method of claim 1, wherein the stored information is utilized to assist in providing a history of electromagnetic energy delivery device use.
 22. The method of claim 1, wherein the stored information is utilized to assist in providing a controllable amount of cooling for a cooling member.
 23. The method of claim 1, wherein the stored information is utilized to assist in providing a controllable delivery rate of cooling delivered from a cooling member.
 24. The method of claim 1, wherein the stored information is utilized to assist in providing an amount of time that the electromagnetic energy delivery device can be used.
 25. The method of claim 1, wherein the stored information is utilized to assist in providing a duration of energy delivery.
 26. The method of claim 1, wherein the stored information is utilized to assist in providing a number of areas treated by the electromagnetic energy delivery device
 27. The method of claim 1, wherein the stored information is utilized to assist in providing a number of times the electromagnetic energy delivery device has been moved relative to the skin surface.
 28. The method of claim 1, wherein the stored information is utilized to assist in providing at least one of time or date of electromagnetic energy delivery device usage.
 29. The method of claim 1, wherein the stored information is utilized to assist in providing a determination of a skin thickness.
 30. The method of claim 1, wherein the stored information is utilized to assist in providing an amount of energy delivered by the electromagnetic energy delivery device.
 31. The method of claim 1, wherein the stored information is utilized to assist in providing a status of the electromagnetic energy delivery device or the electromagnetic energy source.
 32. The method of claim 1, wherein the stored information is utilized to assist in providing information relative to a change of tissue in response to energy delivered by the electromagnetic energy delivery device.
 34. The method of claim 1, wherein the electromagnetic energy delivery device is an RF electrode device and the electromagnetic energy source is an RF source.
 35. The method of claim 34, wherein the stored information is utilized to assist in controlling an amount of current delivered by the RF electrode
 36. The method of claim 34, wherein the stored information is utilized to assist in controlling a temperature of the RF electrode relative to a target temperature
 36. The method of claim 34, wherein the stored information is utilized to assist in providing a maximum number of firings of the RF electrode.
 37. The method of claim 34, wherein the stored information is utilized to assist in providing a maximum allowed voltage that is deliverable by the RF electrode.
 38. A method of creating a tissue effect at a tissue site, comprising: providing an electromagnetic energy delivery device; delivering electromagnetic energy through a skin surface; creating a reverse thermal gradient through the skin surface to sufficiently heat an underlying tissue, wherein a temperature of the skin surface is lower than a temperature of the underlying tissue; detecting a temperature of the skin surface; heating the skin surface and underlying tissue in response to a detected temperature of the skin surface; and creating a tissue effect on at least a portion of the tissue site.
 39. The method of claim 38, wherein the tissue effect is dermal remodeling.
 40. The method of claim 38, wherein the tissue effect is dermal tightening.
 41. The method of claim 38, wherein the tissue effect is wrinkle reduction.
 42. The method of claim 38, wherein the tissue effect is elastosis reduction.
 43. The method of claim 38, wherein the tissue effect is scar reduction.
 44. The method of claim 38, wherein the tissue effect is sebaceous gland removal or deactivation.
 45. The method of claim 38, wherein the tissue effect is a reduction of sebaceous gland activity
 46. The method of claim 38, wherein the tissue effect is hair follicle modification.
 47. The method of claim 38, wherein the tissue effect is adipose tissue remodeling or removal.
 48. The method of claim 38, wherein the tissue effect is spider vein removal
 49. The method of claim 38, wherein the tissue effect is modification of skin irregularities
 50. The method of claim 38, wherein the tissue effect is a creation of scar or nascent collagen
 51. The method of claim 38, wherein the tissue effect is a reduction of skin bacteria activity.
 52. The method of claim 38, wherein the tissue effect is a modification of skin pore size.
 53. The method of claim 38, wherein the tissue effect is an unclogging of skin pores.
 54. The method of claim 38, wherein the tissue effect is a modification of fat tissue.
 55. The method of claim 38, wherein the tissue effect is a modification of muscle tissue.
 56. The method of claim 38, wherein the tissue effect is a modification of facial tissue.
 57. A method for creating a tissue effect at a tissue site, comprising: providing an RF energy delivery device with an energy delivery surface; coupling the RF energy delivery surface with a skin surface; creating a reverse thermal gradient through the skin surface to sufficiently heat the tissue, wherein a temperature of the skin surface is lower than a the temperature of the underlying tissue; detecting a temperature of the skin surface; delivering energy through the skin surface to the underlying tissue in response to a detected temperature of the skin surface; and creating the tissue effect on at least a portion of the tissue site.
 58. The method of claim 57, wherein the tissue effect is dermal remodeling.
 59. The method of claim 57, wherein the tissue effect is dermal tightening.
 60. The method of claim 57, wherein the tissue effect is wrinkle reduction.
 61. The method of claim 57, wherein the tissue effect is elastosis reduction.
 62. The method of claim 57, wherein the tissue effect is scar reduction.
 63. The method of claim 57, wherein the tissue effect is sebaceous gland removal or deactivation.
 64. The method of claim 57, wherein the tissue effect is a reduction of sebaceous gland activity
 65. The method of claim 57, wherein the tissue effect is hair follicle modification.
 66. The method of claim 57, wherein the tissue effect is adipose tissue remodeling or removal.
 67. The method of claim 57, wherein the tissue effect is spider vein removal
 68. The method of claim 57, wherein the tissue effect is modification of skin irregularities
 69. The method of claim 57, wherein the tissue effect is a creation of scar or nascent collagen
 70. The method of claim 57, wherein the tissue effect is a reduction of skin bacteria activity.
 71. The method of claim 57, wherein the tissue effect is a modification of skin pore size.
 72. The method of claim 57, wherein the tissue effect is an unclogging of skin pores.
 73. The method of claim 57, wherein the tissue effect is a modification of fat tissue.
 74. The method of claim 57, wherein the tissue effect is a modification of muscle tissue.
 75. The method of claim 57, wherein the tissue effect is a modification of facial tissue.
 76. A method of creating a tissue effect, comprising: providing an electromagnetic energy source; reducing a temperature of at least a portion of a skin surface, wherein the temperature of the skin surface is less than the temperature of an underlying tissue when the temperature of the skin surface is reduced; non-continuously delivering energy through the skin surface to the underlying tissue; and creating a tissue effect on at least a portion of the underlying tissue.
 77. The method of claim 76, wherein the tissue effect is dermal remodeling.
 78. The method of claim 76, wherein the tissue effect is dermal tightening.
 79. The method of claim 76, wherein the tissue effect is wrinkle reduction.
 80. The method of claim 76, wherein the tissue effect is elastosis reduction.
 81. The method of claim 76, wherein the tissue effect is scar reduction.
 82. The method of claim 76, wherein the tissue effect is sebaceous gland removal or deactivation.
 83. The method of claim 76, wherein the tissue effect is a reduction of sebaceous gland activity
 84. The method of claim 76, wherein the tissue effect is hair follicle modification.
 85. The method of claim 76, wherein the tissue effect is adipose tissue remodeling or removal.
 86. The method of claim 76, wherein the tissue effect is spider vein removal
 87. The method of claim 76, wherein the tissue effect is modification of skin irregularities
 88. The method of claim 76, wherein the tissue effect is a creation of scar or nascent collagen
 89. The method of claim 76, wherein the tissue effect is a reduction of skin bacteria activity.
 90. The method of claim 76, wherein the tissue effect is a modification of skin pore size.
 91. The method of claim 76, wherein the tissue effect is an unclogging of skin pores.
 92. The method of claim 76, wherein the tissue effect is a modification of fat tissue.
 93. The method of claim 76, wherein the tissue effect is a modification of muscle tissue.
 94. The method of claim 76, wherein the tissue effect is a modification of facial tissue.
 95. A method of creating a tissue effect, comprising: providing an electromagnetic energy source; non-continuously reducing a temperature of at least a portion of a skin surface, wherein the temperature of the skin surface is less than the temperature of an underlying tissue; creating a tissue effect on at least a portion of the underlying tissue.
 96. The method of claim 95, wherein the tissue effect is dermal remodeling.
 97. The method of claim 95, wherein the tissue effect is dermal tightening.
 98. The method of claim 95, wherein the tissue effect is wrinkle reduction.
 99. The method of claim 95, wherein the tissue effect is elastosis reduction.
 100. The method of claim 95, wherein the tissue effect is scar reduction.
 101. The method of claim 95, wherein the tissue effect is sebaceous gland removal or deactivation.
 102. The method of claim 95, wherein the tissue effect is a reduction of sebaceous gland activity
 103. The method of claim 95, wherein the tissue effect is hair follicle modification.
 104. The method of claim 95, wherein the tissue effect is adipose tissue remodeling or removal.
 105. The method of claim 95, wherein the tissue effect is spider vein removal
 106. The method of claim 95, wherein the tissue effect is modification of skin irregularities
 107. The method of claim 95, wherein the tissue effect is a creation of scar or nascent collagen
 108. The method of claim 95, wherein the tissue effect is a reduction of skin bacteria activity.
 109. The method of claim 95, wherein the tissue effect is a modification of skin pore size.
 110. The method of claim 95, wherein the tissue effect is an unclogging of skin pores.
 111. The method of claim 95, wherein the tissue effect is a modification of fat tissue.
 112. The method of claim 95, wherein the tissue effect is a modification of muscle tissue.
 113. The method of claim 95, wherein the tissue effect is a modification of facial tissue. 